=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295759751
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GREGG RANDALL RICHARDS RPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 512 W LINE ST SUITE C
-----------------------------------------------------
City | BISHOP
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93514-3347
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-873-7230
-----------------------------------------------------
Fax | 760-872-3418
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 512 W LINE ST SUITE C
-----------------------------------------------------
City | BISHOP
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93514-3347
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-873-7230
-----------------------------------------------------
Fax | 760-872-3418
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 00PT66310
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------